Would-be doctors compete for the best medical schools. Actual doctors compete for the best NHS jobs. NHS hospitals compete with private practice for consultants’ time, and they compete with non-healthcare employers to retain nurses. General practitioners have partly been competing for NHS patients since 1948. So have hospitals since 1991. Companies compete to provide the NHS with new medicines and diagnostics. NHS researchers compete for grants. The BMJ competes with other medical journals. And the NHS competes with schools, prisons, and the armed forces for public funding.

So competition in the NHS is both longstanding and inevitable. It involves not a binary yes/no ideological choice, but pragmatic and nuanced judgments about how—not whether—to make use of it.

Competition is not a silver bullet. Strong professionalism, greater performance transparency, sophisticated commissioning, and more rigorous independent regulation are also needed—as recent failures at care homes and at Mid-Staffordshire hospital graphically demonstrate. But competition has its place in policy makers’ therapeutic arsenal, and upping the dose could benefit patients, taxpayers, …

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